Register as a New Client – Clearwater Medical Qigong

Name

First

Last

City

State

Phone Number

Age

Relationship Status

Single
Married
Domestic Partner
Widowed

Emergency Contact

Telephone

Relationship

Personal Reasons for Seeking Medical Qigong Treatment

Duration of condition(s)

What do you believe caused this condition?

Currently in the care of Health Practioner(s)

Purpose of care:

Current Medication / Herbs:

Pegnant

Yes
No
N/A

Do You Have

Cancer and severe mental disorders are both speciality areas within Medical Qigong that I currently do not work with. If you have either of these I am happy to refer you to a specialist.

Surgeries / Biopsies:

Lifestyle

Religious/spiritual preference

Do you have any spiritual concerns?

Diet

Emotional Environment – Are you happy?

Home:

Work:

Recurring emotional pattern(s)?

in What Telephone

Rate current level of pain or discomfort?

Selected Value: 0

(0=No Pain / 10=Unbearable Pain)

Frequency of pain:

often
occasionally
infrequently

Electronic Consent Agknowledgement

I understand that by typing my name below I am providing my Electronic Signature.

Your Electronic Signature (Full Name)

I understand that Erin Ecklund is not a licensed physician in Wisconsin and does not possess a license from the state of Wisconsin. I also understand that medical qigong is a form of complementary and alternative medicine not licensed by the State of Wisconsin. In practicing complementary and alternative medicine Erin Ecklund seeks to support rather than replace the care of your existing physician, therapist, or acupuncturist. Erin Ecklund provides medical qigong treatments and exercises designed to assist clients in maintaining physical, emotional, and spiritual well-being. Medical qigong, one of the four main branches of Chinese medicine, is a system of health care that recognizes the root causes of symptoms or disease, and treats the client as a whole person. Practiced as an adjunct to Western medicine, medical qigong addresses the energetic imbalances or blockages that contribute to illness. Medical qigong is not a panacea but a healing modality that has been practiced in China for over 2,000 years. By signing below, I understand the nature of medical qigong therapy and the above-referenced practitioner’s qualifications to practice medical qigong therapy. I consent to participate in medical qigong treatments and/or instruction.

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